Search

We conclude that the infusion sleeve can be used in conjunction with standard angioplasty equipment to deliver agent at the site of angioplasty. Further studies are ongoing to determine the safety and efficacy of this approach.

Between January 2003 and September 2006, a total of 2,541 patients had percutaneous coronary intervention (PCI). Of these, 202 (226 grafts) had at least one saphenous vein graft (SVG) intervention. Adjunctive distal embolic protection (DEP) devices were attempted in 123 SVGs (54.4%). The 30-day major adverse cardiac event (occurrence of death, myocardial infarction, or target vessel revascularization) rate in the overall group was 11.9%. The presence of angiographic thrombus independently predicted DEP use while the presence of in-stent restenosis predicted no DEP use. Although the presence of all angiographic technical feasibility criteria independently predicted DEP use, only 72 (32.4%) and 33 (14.6%) of the SVGs would have been eligible for the occlusive balloon- and filter-based distal embolic criteria, respectively. The most common technical reason for ineligibility was a graft size smaller than 3.0 mm, followed by the lack of a long enough landing zone. In a subset of 21 (9.3%) completely occluded lesions which would have excluded DEP use, angiographic success was 66.7%, and that was predicated on successful debulking with rheolytic thrombectomy in 13 (61.9%) with subsequent DEP in 5 (23.8%). In conclusion, not all grafts can be protected, and even in those that can, such protection may be incomplete. Newer embolic protection devices, such as the Proxis((R)), were recently introduced to expand the applicability to a wider population of vein grafts. However, further design improvements such as device miniaturizations applicable to sub-3.0-mm vessels and better particle removing/filtering mechanisms are needed in order to expand the use of embolic protection to reduce the persistently high complication rates associated with this difficult- to-treat subset of patients.

The predictors of 5-year cardiac survival in patients with multivessel coronary artery disease (CAD) undergoing percutaneous transluminal coronary angioplasty (PTCA) were analyzed in a series of 637 consecutive patients. The average age was 59 +/- 11 years in 472 men and 165 women. Diabetes mellitus, previous myocardial infarction and unstable angina were present in 119 (19%), 261 (41%) and 305 (47%) patients, respectively. Angiographically, 460 patients had 2-vessel and 177 patients had 3-vessel CAD. The left ventricular contraction score was greater than or equal to 12 in 55 patients. Angiographic success (less than 50% residual stenosis) was achieved in 85% of the 1,343 narrowings and clinical success was obtained in 526 (83%) of the 637 patients. Complete revascularization was obtained in 177 (34%) of 526 successful patients. Procedure-related complications resulted in death in 9 patients (1.4%), in Q-wave myocardial infarction only in 6 patients (0.9%) and in emergency bypass surgery in 44 patients (6.9%) (of whom 10 had Q-wave myocardial infarction). Follow-up for greater than or equal to 1 year and up to 6 years after PTCA was obtained in 608 (95%) of the 637 patients. To determine the predictors of 5-year cardiac survival, 28 clinical, angiographic and procedural variables were analyzed by Cox proportional-hazards regression. The estimated 5-year survival after PTCA was 88 +/- 2% in successful patients and 77 +/- 5% in patients in whom PTCA was unsuccessful (p less than 0.001). When clinical success was forced into the Cox regression, the left ventricular contraction score of greater than or equal to 12, diabetes mellitus and age greater than or equal to 65 years showed additional adverse effects on survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Relative contraindications to coronary angioplasty have been large amounts of jeopardized myocardium and poor left ventricular function. To prevent possible hemodynamic collapse after balloon occlusion or acute vessel closure in such high risk patients, a cardiopulumonary bypass system capable of providing up to 6 liters/min output was employed prophylactically. This technique, termed supported angioplasty, results in reductions of preload and afterload and allows prolonged balloon inflations in critical coronary vessels.A National Registry of 14 centers performing elective supplied angioplasty was formed to collate the initial experience with high risk patients. Suggested indications were ejection fraction 75 years of age and had left main coronary artery stenosis. Patients without these two factors had a hospital mortality rate of 2.6%. Symptomatic improvement (lessening of New York Heart Association chest pain classification by at least two classes) occurred in 91% of the patients surviving hospitalization. During the follow-up period of 1 to 12 months, three patients died of cardiac complications.This multicenter experience suggests that supported angioplasty can be safely performed with the expectation of good symptomatic improvement and short-term survival in high risk patients other than elderly individuals with left main coronary artery stenosis.

Heparin with adjunctive glycoprotein IIb/IIIa platelet receptor (GP IIb/IIIa) inhibitors has demonstrated its effectiveness in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Bivalirudin, a direct thrombin inhibitor, has recently been shown to be an effective alternative for patients undergoing elective PCI.To assess the angiographic and clinical outcomes of adjunctive pharmacological strategies in a high-risk population presenting with ACS.Of 891 consecutive PCI patients with ACS, 304 received bivalirudin (60.5% male, 68+/-11 years) and were compared with 283 who received heparin (58.7% male, 66+/-12 years). A 30-day major adverse cardiac event was defined as the occurrence of cardiac death, nonfatal myocardial infarction, urgent revascularization or major hemorrhage.Adjunctive GP IIb/IIIa inhibitors were used in 14.1% of the bivalirudin group and in 72.4% of the heparin group (P0.010). The occurrence of Thrombolysis In Myocardial Infarction (TIMI) flow less than grade 3 was lower and the achievement of angiographic success was higher in the bivalirudin group than in the heparin group (5.2% versus 8.2%, 94.7% versus 89.7%, P=0.039 and P0.010, respectively). There was no difference between groups in the incidence of bleeding events (bivalirudin 2.0% versus heparin 3.5%, P not significant) and in 30-day major adverse cardiac events (bivalirudin 8.3% versus heparin 5.7%, P=0.223).In the high-risk cohort undergoing PCI, bivalirudin with provisional GP IIb/IIIa inhibitors achieved better angiographic results. Although not powered to show a difference, and while acknowledging that a selection bias could have affected the data, the present study showed that bivalirudin may be as clinically effective and safe as heparin with adjunctive GP IIb/IIIa inhibitors.

The aim of this multicenter pilot study was to evaluate the acute safety and efficacy of the dexamethasone-eluting stent (0.5 mug/mm(2) of stent) implanted in patients with de novo single-vessel disease. This study included 71 patients, 42% of whom had unstable angina pectoris. An appropriately sized BiodivYsio Matrix Lo stent loaded with a total dexamethasone dose of 0.5 mug/mm(2) of stent was used. Technical device success rate was 95%. Six-month MACE occurred in two patients (3.3%). Binary restenosis rate was 13.3%. Late loss was 0.45. Late loss and percent diameter stenosis were lower in the unstable angina pectoris patients compared to the stable patients (0.32 +/- 0.39 vs. 0.60 +/- 0.55 mm, P < 0.07, and 26.86 +/- 14 vs. 38.40 +/- 16%, P < 0.02). This study demonstrated the feasibility and safety of the implantation of a dexamethasone-eluting stent and its effect on in-stent neointimal hyperplasia. (C) 2003 Wiley-Liss, Inc.

Background The purpose of this study was to test whether coronary revascularization with ablation of either excimer laser or rotational atherectomy can improve the initial angiographic and clinical outcomes compared with dilatation (balloon angioplasty) alone. Methods and Results At a single center, a total of 685 patients with symptomatic coronary disease warranting elective percutaneous revascularization for a complex lesion were randomly assigned to balloon angioplasty (n=222), excimer laser angioplasty (n=232), or rotational atherectomy (n=231). The primary end point was procedural success (diameter stenosis P= .0019), but no difference was observed in major in-hospital complications (3.2% versus 4.3% versus 3.1%, P= .71). At the 6-month follow-up, revascularization of the original target lesion was performed more frequently in the rotational atherectomy group (42.4%) and the excimer laser group (46.0%) than in the angioplasty group (31.9%, P= .013). Conclusions Procedural success of rotational atherectomy is superior to laser angioplasty and balloon angioplasty; however, it does not result in better late outcomes. The role of plaque debulking before balloon dilatation in percutaneous coronary revascularization remains to be fully defined.

UNLABELLED To assess whether differences in design (geometry, flexibility) and material (electrostatic behavior) may influence the acute and late outcome following intracoronary stent implantation in the treatment of acute or threatened closure after prolonged balloon inflations, 50 patients were randomized to receive either a Palmaz-Schatz stent (n = 25) or a Strecker stent (n = 25). RESULTS [table: see text] CONCLUSION Both Palmaz-Schatz and Strecker stents are equally effective in restoring vessel patency in bail-out situations. The incidence of complications is high and similar for both stents if they were used after failed prolonged balloon inflations. Differences in design and material do not seem to influence the results.

To assess the outcome of percutaneous transluminal coronary angioplasty (PTCA) in patients with severe left ventricular (LV) dysfunction and to determine the predictors of mortality, 73 patients with LV ejection fraction less than or equal to 40% who underwent initial PTCA were analyzed. The majority of patients had prior (greater than 1 week) myocardial infarction (62 patients, 85%). Congestive heart failure and unstable angina were present in 24 (45%) and 49 (67%) patients, respectively. Multivessel coronary artery disease was present in 60 (83%). The LV ejection fraction ranged from 14 to 40% (mean 34%). Intraaortic balloon pump (15%) and percutaneous cardiopulmonary bypass support (4%) was used infrequently. Angiographic success was obtained in 109 of 128 lesions (85%) attempted. Complete revascularization was obtained in 16 of 60 patients with clinical success. Procedure-related mortality was 5% (4 patients). All patients were followed from greater than or equal to 6 to less than or equal to 71 months (average 26). The estimated survival was 79 +/- 5%, 74 +/- 6%, 66 +/- 7% and 57 +/- 8% at 1, 2, 3 and 4 years, respectively. A Cox regression analysis revealed that the presence of congestive heart failure, a lower LV ejection fraction and a higher myocardial jeopardy score for contractile myocardium were independent predictors of survival after PTCA in patients with LV dysfunction. In conclusion, a high-risk subset can be identified among patients with severe LV dysfunction who undergo PTCA.

The prevalence and characteristics of silent myocardial ischemia as detected by 24-hour ambulatory electrocardiography ST-segment depression were prospectively assessed in 94 patients examined early (1 to 3 months) and 184 patients examined late (12 months) after coronary artery bypass grafting (CABG), and followed for a mean of 48 +/- 11 (range 4 to 62) months. The relation of ambulatory electrocardiographic silent ischemia to evidence of completeness of revascularization as defined by cardiac angiography performed 1 and 12 months after CABG, and to prognosis by follow-up of adverse clinical events was analyzed. Silent ischemia was detected early in 20% (19 of 94) and late in 27% (50 of 184) of patients, and showed a mean frequency of episodes ranging from 6 to 10 episodes/24 hours with a mean duration ranging from 15 to 23 minutes. The circadian distribution of episodes disclosed a significant peak of ischemic activity during the period of 6 A.M. to noon and a secondary peak between 6 P.M. and midnight (p less than 0.01 and p less than 0.001, respectively). Silent ischemia was not found by univariate analysis to be associated with graft or anastomotic site occlusions, low graft flow rates, grafted arteries with significant distal residual stenoses or ungrafted stenotic native coronary arteries. Kaplan-Meier analysis of time to cardiac event showed that silent ischemia was not predictive of an adverse clinical event in the early years after CABG. Cox regression analysis of 30 covariates only disclosed age (relative risk 1.06 [95% confidence interval, 1.01 to 2.94]) as having an effect on time to adverse clinical event.(ABSTRACT TRUNCATED AT 250 WORDS)

The safety and short-term therapeutic benefit of multilesion percutaneous transluminal coronary angioplasty was assessed in 135 patients, 66 of whom had a minimum of 6 months of follow-up study. Primary success, defined as successful dilation of the most critical lesion or all lesions attempted without major in-hospital complications was obtained in 117 (87%) of the 135 patients. Cardiac complications associated with the procedure were uncommon; prolonged angina occurred in 5% and myocardial infarction in 3%; emergency coronary bypass surgery was performed in 4% of the patients. There were no deaths. Complete revascularization was achieved in 46% of the 117 patients with a primary success. Of the 66 patients eligible for 6 month follow-up, 80% had an uncomplicated course and required no further procedures. Clinical improvement by at least one angina functional class was observed in 90% of the patients. Cardiac events such as the need for a second revascularization procedure were significantly more common in patients who had incomplete versus complete revascularization (35 versus 9%; p = 0.018). Repeat coronary angiography performed an average of 5 months after angioplasty revealed restenosis in 18 of 22 symptomatic patients and 3 of 9 asymptomatic patients. Restenosis occurred at the site of a single dilation in 12 patients, at two sites in 8 patients and at three sites in 1 patient. Thus, multilesion coronary angioplasty is an important therapeutic option for selected patients with multivessel disease and can be performed with relatively low risk. Improvement in angina status can be expected even in patients who have incomplete revascularization. The need for a second revascularization procedure is significantly greater when incomplete revascularization is obtained.

Acute myocardial ischemia is known to cause impairment of both left ventricular systolic and diastolic function. To further investigate these changes as well as their relation to common clinical variables (electrocardiographic [ECG] changes and chest pain), 32 patients were evaluated with Doppler echocardiography during coronary angioplasty. Doppler indexes of left ventricular diastolic function included the ratios of peak early to late and peak early to mean diastolic velocities as well as the ratios of early to late and first third to total velocity integral (one-third filling fraction). All diastolic indexes showed significant impairment by 15 seconds after coronary occlusion (ratio peak early to late filling velocity: 1.11 versus 0.96, p < 0.01; ratio peak early to mean filling velocity: 1.9 versus 1.7, p < 0.01; ratio early to late velocity integral: 1.58 versus 1.25, p < 0.01; one-third filling fraction: 41.2 versus 37.7, p < 0.01).Left ventricular systolic function was evaluated during coronary occlusion both qualitatively, as assessed by the appearance of a new wall motion abnormality on two-dimensional echocardiography (mean 28.8 seconds), and quantitatively by measurement of systolic percent area change on the two-dimensional short-axis view as well as the Doppler echocardiographic stroke integral index. Systolic indexes did not show significant change until 30 seconds after balloon inflation (percent area change: 42.8 versus 29.2, p < 0.01; stroke integral index: 11.04 versus 9.36, p < 0.01).ECGs were performed at 15 second intervals. New ST segment elevation of 1 mm occurred in 26 of the 32 patients studied, whereas only half of the study patients developed typical anginal chest pain during coronary artery occlusion. In general, the ECG changes preceded the development of chest pain as well as left ventricular systolic dysfunction except in patients with significant collateral circulation. Diastolic left ventricular dysfunction was the earliest change seen after coronary occlusion regardless of the presence of collateral circulation. Systolic and diastolic abnormalities were noted to return to baseline by 15 seconds after balloon deflation.This study confirms that the response to acute transient myocardial ischemia involves both systolic and diastolic dysfunction. In addition, these data suggest that the ischemic response is heralded by left ventricular diastolic impairment followed by ECG changes, systolic impairment and angina, respectively.

The prognostic value of early exercise testing after successful coronary angioplasty was determined in 196 and 225 consecutive patients with single-vessel and multivessel coronary disease, respectively, who underwent a symptom-limited exercise test within 30 days of the procedure. The incidence of exercise-induced ST segment depression greater than or equal to 1 mm was significantly greater in patients with multivessel versus single-vessel disease (27% versus 14%; p less than 0.005) and in patients with multivessel coronary disease who had incomplete versus complete revascularization (36% versus 10%; p less than 0.001). An abnormal exercise ECG result was associated with a significantly increased risk of cardiac events in patients with multivessel disease but not in patients with single-vessel disease. Exercise-induced angina occurred in a small and similar proportion of patients with single and multivessel coronary disease (8% versus 12%). The presence of exercise-induced angina was associated with a higher incidence of follow-up cardiac events in patients with multivessel disease and incomplete revascularization (52% versus 33%; p less than 0.05). Exercise duration was significantly less in patients with multivessel disease who had a subsequent cardiac event compared with that in patients who did not have such an event (458 +/- 168 versus 519 +/- 156 seconds; p = 0.01). Thus an abnormal exercise ECG finding within 1 month of successful coronary angioplasty is predictive of subsequent cardiac events in patients who have multivessel disease. The prognostic content of the test might be further improved if the test were performed several months after the procedure when the risk of restenosis is greatest.

The effects of diltiazem during transient myocardial ischemia were studied in 17 patients (age 58 +/- 11 years, 12 men, 5 women) undergoing 1-vessel left anterior descending percutaneous transluminal coronary angioplasty (PTCA). After hemodynamic, echocardiographic and electrocardiographic data were obtained during the control ischemic periods, diltiazem (10 mg intravenous bolus with 500 micrograms/min infusion) was given and 15 minutes later ischemia reinduced. Diltiazem reduced mean arterial pressure (113 +/- 16 to 95 +/- 15 mm Hg, p less than 0.05) and heart rate-pressure product (p less than 0.05) with no change in heart rate, pulmonary pressures or coronary (sinus, thermodilution technique) blood flow at rest. After diltiazem, times to ischemia-induced 1.0 mm ST-segment elevation (28 +/- 10 to 42 +/- 17 seconds, p less than 0.05) and new left ventricular wall motion abnormalities (by 2-dimensional echocardiography, 24 +/- 8 to 36 +/- 12 seconds, p less than 0.001) were prolonged without significant augmentation of great cardiac vein flow during coronary occlusion. Left ventricular (LV) ejection fraction decreased from 51 +/- 7 to 41 +/- 12% (p less than 0.05) during control ischemia, but declined less after diltiazem (54 +/- 12 to 47 +/- 14%, difference not significant; 47 +/- 14 vs 41 +/- 12%, p less than 0.01). Diltiazem can attenuate, but not abolish, some of the effects of myocardial ischemia on LV function during transient coronary artery occlusion. These data support the use of diltiazem as a beneficial adjunct that may be used acutely and safely during routine PTCA.

The acute effects of intravenous diltiazem on exercise performance were studied in 10 patients with coronary artery disease. Haemodynamic measurements were made at rest and during exercise before and after 0.5 mg kg-1 of diltiazem. Diltiazem prolonged the duration of exercise (+2.85 min, P less than 0.001) and delayed the onset of ischaemic ST depression or angina in all patients. The highest tolerated heart rate and pressure rate product were increased in all but one patient after diltiazem. At rest diltiazem decreased mean arterial pressure (-10.8%, P less than 0.005), systemic vascular resistance (SVR) (-11.8%, P less than 0.05) and left ventricular stroke work index (SWI) (-14.1%, P less than 0.005). During exercise under diltiazem therapy, at the level achieved before the drug, the pulmonary capillary wedge pressure (-30%, P less than 0.005) and the SVR (-13.6%, P less than 0.02) were lowered, the SWI (+13%, P less than 0.01) was increased; at the end of exercise only the SVR (-14%, P less than 0.05) was reduced. Two patients experienced angina on lying down and one had orthostatic hypotension after exercise with diltiazem. This study indicates that intravenous diltiazem is a potentially useful agent for the treatment of angina by reducing myocardial oxygen demand at rest and by improving left ventricular performances on exercise.

Three hundred ninety patients who had successful coronary angioplasty were studied by treadmill exercise testing to determine the incidence and prognostic importance of silent and symptomatic myocardial ischemia in this patient subset. All patients were followed for an average of 11 months. During exercise, 81 patients (20%) had abnormal exercise-induced ST-segment depression without chest pain (group 1). Twenty patients (5%) had chest pain without ST changes (group 2). Twenty-one patients (5%) had both exercise-induced chest pain and ST-T-segment depression (group 3) and 268 patients (70%) had a normal exercise test with no chest pain (group 4). The groups were similar with respect to age, sex, history of previous myocardial infarct and previous coronary bypass surgery. Group 4 included more patients with complete revascularization. Mutually exclusive cardiac events were defined as cardiac death, nonfatal myocardial infarction, class III angina and additional revascularization (coronary angioplasty, coronary artery bypass surgery). The cardiac event rate in groups 1, 2 and 3 were significantly higher than in group 4 (40, 45 and 43 vs 22%; p = 0.001). There were 4 cardiac deaths and 4 nonfatal myocardial infarctions in group 1 compared to 2 cardiac deaths and 3 nonfatal myocardial infarctions in group 4 (p = 0.03 and 0.05, respectively). The event rates in groups 1, 2 and 3 patients with multivessel disease were significantly greater than in group 4 (44, 60 and 47 vs 22%; p = 0.002). Thus, exercise-induced myocardial ischemic episodes, both symptomatic and silent, early after coronary angioplasty are predictive of an unfavorable prognosis and serious cardiac events, particularly in patients with multivessel disease and incomplete revascularization.

The effect of aortic balloon valvuloplasty on left ventricular diastolic function and filling was investigated in 44 adult patients with severe aortic stenosis. Two-dimensional and Doppler echocardiography was performed in all patients before and 24 h after valvuloplasty. In 19 patients (short-term group) repeat studies were performed at 3 (n = 2) and 6 (n = 17) months. Left ventricular relaxation, chamber stiffness and filling were assessed in 16 patients (immediate post-valvuloplasty group) before and immediately after valvuloplasty by simultaneous micromanometer left ventricular pressure tracings and echocardiograms. Immediately after valvuloplasty, relaxation was slightly impaired in the immediate post-valvuloplasty group, as reflected by the isovolumic relaxation time constant (56 +/- 26 to 68 +/- 39 ms; p less than 0.01) and maximal negative dP/dt (2,063 +/- 640 to 1,767 +/- 495 mm Hg/s; p less than 0.001). The chamber stiffness constants and diastolic filling dynamics were unchanged immediately after valvuloplasty. Twenty-four hours after valvuloplasty, patients without mitral regurgitation (n = 24) showed increases in the peak early filling velocity (72 +/- 31 to 83 +/- 28 cm/s; p less than 0.05) and peak early to atrial filling velocity ratio (0.8 +/- 0.6 to 1.0 +/- 0.7; p less than 0.05). However, in patients with mitral regurgitation (n = 20), the diastolic filling dynamics were not significantly changed. In the short-term group at the 3 to 6 month follow-up period, patients without mitral regurgitation (n = 12) showed striking increases compared with pre-valvuloplasty values in the peak early filling velocity (66 +/- 21 to 93 +/- 31 cm/s; p less than 0.02), peak early to atrial filling velocity ratio (0.6 +/- 0.2 to 0.9 +/- 0.4; p less than 0.02) and early time-velocity integral (9 +/- 4 to 16 +/- 6 cm; p less than 0.002). In patients with mitral regurgitation (n = 7) decreases occurred in the peak early filling velocity (123 +/- 32 to 106 +/- 28 cm/s; p less than 0.05) and peak early to atrial filling velocity ratio (1.5 +/- 0.7 to 1.1 +/- 0.6; p less than 0.05). Functional class in hospital improved after valvuloplasty (3.1 +/- 1.0 to 2.6 +/- 0.9; p less than 0.001) and correlated modestly with the percent decrease in Doppler-derived peak gradient (rs = 0.41, p less than 0.02) and mean gradient (rs = 0.36, p less than 0.05), but did not correlate with changes in aortic valve area, left ventricular ejection fraction or diastolic filling variables.(ABSTRACT TRUNCATED AT 400 WORDS)

To assess the usefulness of exercise echocardiography in the follow-up of patients after percutaneous transluminal coronary angioplasty (PTCA), we studied 56 patients at rest and immediately following exercise with two-dimensional echocardiography. Sixty-nine of 73 stress/echo studies (94%) were suitable for interpretation. Seventeen patients (group I) with significant coronary artery disease (CAD) were studied before and after PTCA. Sixteen patients with coronary disease not undergoing PTCA (group II) and 23 individuals without significant coronary disease (group III) served as age-matched controls. Left ventricular ejection fraction did not change significantly in group I patients prior to PTCA (56 +/- 7 versus 54 +/- 12, p = ns) or in group II patients (52 +/- 10 versus 56 +/- 15, p = ns), rest versus immediate after exercise measurements. Following angioplasty, left ventricular ejection fraction increased in group I patients from 55 +/- 7 to 65 +/- 8, p less than 0.001 from rest to exercise, and to a similar extent in group III individuals (55 +/- 6 to 66 +/- 8, p less than 0.001). Electrocardiographic (ECG) evidence of ischemia (greater than 1 mm ST segment depression) was found in 13 of 17 group I patients prior to PTCA and in 8 of 16 group II patients (CAD). None of the 25 normal patients and four of the group I patients following PTCA had abnormal ECG changes with exercise. New exercise-induced echocardiographic wall motion abnormalities were found in 12 of 17 group I patients prior to PTCA and in none of the group I patients following PTCA.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary angioplasty is a widely applied revascularization procedure for patients with multivessel coronary artery disease. However, follow-up in this patient subgroup is relatively limited. From 1983 to 1986, coronary angioplasty was performed in 349 and 121 patients with, respectively, two- and three-vessel coronary disease with a primary success rate of 83 and 88%. The in-hospital mortality rate was 2.8% (13 of 470 patients). Complete revascularization was achieved in 128 patients. Among the 397 patients with a successful outcome, 373 (94%) were followed up ≥ 1 year; 79% were free of death, nonfatal myocardial infarction or the need for coronary bypass grafting, and 82% of patients had symptomatic improvement by at least one angina functional class. A second coronary angioplasty procedure was required in 13% of patients.After a mean follow-up period of 27 months, an increased incidence of coronary bypass grafting was noted in patients with incomplete versus complete revascularization (16 versus 7%, p < 0.05). Among the 222 patients who had repeat cardiac catheterization performed an average of 7 months after angioplasty, 103 were symptomatic; 50% of the 222 patients had at least one vessel with ≥50% restenosis and 14% of patients had multiple restenoses.In conclusion, coronary angioplasty can be performed with a high initial success rate and marked symptomatic improvement in patients with multivessel coronary disease. However, in this group's experience, the majority of patients selected for coronary angioplasty with multivessel coronary disease will have incomplete revascularization that can be predicted in the majority of patients before the procedure. The risk of subsequent cardiac events over 2 years of follow-up is small but is increased in patients with incomplete revascularization.

Although recent clinical experience indicates a high success rate, percutaneous transluminal coronary angioplasty (PTCA) is still associated with serious complications which usually occur during or shortly after the procedure and are principally related to the lesion or segment of vessel being dilated. We report 2 cases of subacute progression within months of left main stenosis following successful, uncomplicated left anterior descending (LAD) coronary PTCA. Identification of left main trunk involvement may mandate earlier follow-up or intervention.

When significant residual stenosis of a coronary artery is observed after successful early streptokinase (STK) therapy for acute myocardial infarction, one is tempted to complete the procedure by percutaneous transluminal angioplasty (PTCA) or early bypass surgery. 1–3

diagnosis. Angiographic definition of the aneurysm depends on the appearance of contrast material in the left atrium during the levophase of a pulmonary arteriogram. Left atria1 aneurysms have been associated with other cardiovascular congenital abnormalities. These include atria1 septal defects,4 persistent left superior vena cava,5 and a renal artery anomaly.6 None of the above anomalies are confirmed by the cardiac catheterization. Instead, partial anomalous pulmonary venous drainage from the left lung into the right atrium is detected from selective pulmonary arterial injection of green dye. However, we cannot selectively cannulate the anomalous return. The combination of left atria1 appendage aneurysm and anomalous pulmonary venous drainage is so rare that this is believed to be the first documented case. Most authors3,7 have recommended surgical resection of left atria1 aneurysms because of the propensity for embolic complications. Although we agree with this general approach, we did not follow this course with the present patient. Our reasons for following this conservative approach included consideration of the age of the patient, no thrombus seen in two-dimensional echocardiographic examination, the long period of symptomatic arrhythmias without embolic events, and the patient’s lack of symptoms when taking verapamil. We did, however, institute anticoagulation with warfarin. The need for preoperative catheterization has been questioned by some.6 However, we believe-given the findings of associated congenital abnormalities such as ours and those congenital anomalies described by othersthat cardiac catheterization should be performed in all patients in whom surgical resection of the aneurysm is planned. In summary, true congenital aneurysms of the left atria1 appendage and left atria1 wall are rare but clinically important lesions. The complications associated with this abnormality can be devastating, especially thromboembolism and cardiac arrhythmia; for these reasons, surgical resection is recommended in most cases. There may also be other important cardiovascular congenital anomalies present in these patients that may need further evaluation. Two-dimensional echocardiography is a safe and reliable means of diagnosing this entity.

The haemodynamic effects of flecainide were compared in three different subsets of patients with documented coronary disease. Ten patients (A) had no heart failure, 5 patients were on beta blockers (B) and 5 patients had overt heart failure (C). Flecainide was associated with negative inotropic effects that were relatively more pronounced in patients with left ventricular dysfunction: pulmonary wedge pressure increased by 27% in A, by 31% in B and by 42% in C; left ventricular stroke volume and stroke work decreased respectively by 10 and 12% in A, 21 and 19% in B, 26 and 28% in C. Ejection fraction decreased by 9% in A, 13% in B and 20% in C, in relation with an increase in end systolic volume (+9% in A, +10% in B and +5% in C). Absolute changes, however, were not significantly different from one group to another except for the increase of systemic vascular resistance which was more pronounced in C as compared with the other groups. The myocardial depression was also confirmed by the fall in dP/dt that was maximal at the end of injection; dP/dt remained depressed 15 min later despite some improvement. Flecainide thus exerts negative inotropic effects that are maximal at the end of infusion and may be of importance in patients with established left ventricular dysfunction.

The hemodynamic effects of flecainide acetate, a new class I antiarrhythmic agent, were studied in 10 patients with coronary heart disease. The drug was injected intravenously at a dose of 2 mg/kg over 30 minutes. The mean drug plasma level achieved was 394 ng/ml (range 329 to 470). The heart rate did not change, but a significant increase (p less than 0.001) in P-R (+17%), QRS (+15%), and Q-T (+7%) duration occurred after drug administration. Negative inotropic effects also were observed and consisted of an increase (p less than 0.01) in pulmonary wedge pressure (+27%) and a decrease (p less than 0.01) in stroke index (-10%), left ventricular stroke work index (-12%), and left ventricular ejection rate (-11%). No significant change in mean aortic pressure or systemic and pulmonary vascular resistance occurred. Left ventriculography performed after drug infusion revealed a significant increase (p less than 0.01) in systolic volume (+9%) and a decrease in ejection fraction (-9%) and mean velocity of circumferential fiber shortening (Vcf) (-13%). A progressive and significant decrease of dP/dt was observed during drug infusion, but 15 minutes after the injection, dP/dt had returned to near basal values. Thus, flecainide acetate has slight, but significant negative inotropic effects, particularly conspicuous during drug infusion. The drug should be administered with caution in patients with poorly compensated heart.

We describe a patient in whom a brachial arterial cutdown done at the same site for percutaneous transluminal angioplasty immediately after uncomplicated percutaneous brachial coronary arteriography revealed the percutaneous sheath in a deeper, smaller, and more lateral artery than the brachial artery, complicating placement of the guiding catheter. This case illustrates the potential hidden hazard of normal brachial artery bifurcation variants, which may be responsible for some of the potential complications encountered in percutaneous brachial artery catheterization techniques.

Extensive data are available on the results of nonoperative coronary revascularization using percutaneous transluminal coronary angioplasty (PTCA) in patients over the age of 65, 1–3 but few data are available in the subgroup of patients in their octogenarian years. We attempted to ascertain clinical data and results in patients older than 80 years of age undergoing PTCA in our hospital.

The influence of continued cigarette smoking on restenosis after percutaneous transluminal coronary angioplasty (PTCA) was retrospectively determined through a study of 160 patients with primary success who underwent follow-up angiography after a mean of 7 +/- 7 months. The average number of narrowings at risk for restenosis was 1.7/patient in the 84 patients who continued to smoke (group 1) and 1.9/patient in the 76 patients who stopped smoking at the time of PTCA (group 2) (difference not significant). The 2 patient groups at baseline were similar with respect to gender, frequency of diabetes mellitus, number of pack/year smoking, angina class and number of diseased coronary arteries. The location of the dilated narrowings, the residual luminal diameter stenosis and the transstenotic gradient after the procedure were similar in both groups. The recurrence of angina greater than or equal to class II was the reason for restudy in 43% and 36% of group 1 and group 2 patients, respectively. Restenosis, defined as the presence of greater than or equal to 50% narrowing at the site of previous successful dilatation at follow-up angiography, was significantly higher in group 1 compared with group 2 patients (55% vs 38%, p = 0.03). Continued smoking was selected as an independent predictor of restenosis by logistic regression analysis. The incidence of coronary artery disease progression (14% vs 10%) was not significantly different between the 2 groups. In conclusion, continued smoking after successful PTCA is associated with an increased risk of restenosis. The higher restenosis rate in smokers emphasizes the need to strengthen educational programs after PTCA.

To determine the predictors of long-term outcome after repeat percutaneous transluminal coronary angioplasty (PTCA), we analyzed the immediate and follow-up results of 144 patients who underwent a second PTCA procedure for restenosis of a previously successfully dilated lesion. Clinical success was obtained in 94% of patients. Emergency coronary bypass graft surgery was required in two patients (1%). Of the 136 successfully treated patients, 126 were followed for a duration of 6 to 36 months (mean 16, median 12 months). The follow-up coronary events (mutually exclusive) included cardiac death (2%), nonfatal myocardial infarction (2%), coronary bypass surgery (15%), and third PTCA (9%). According to results of Cox regression analysis, the independent variables associated with an increased risk of recurrent coronary events after repeat PTCA were: dilatation of a proximal left anterior descending artery stenosis at both initial and second PTCA (p = 0.001), time interval between the initial and the second PTCA less than or equal to 3 months (p = 0.001), multiple versus single-lesion redilatation at the time of repeat PTCA (p = 0.002), and the presence of diabetes mellitus (p = 0.005). Thus repeat PTCA for restenosis is a safe and efficacious procedure, and it provides excellent long-term outcome in the majority of patients. Dilatation of a proximal left anterior descending artery lesion, a short time interval between the first and second PTCA procedures, diabetes mellitus, and redilatation of multiple lesions are predictors of recurrent clinical events after a second PTCA. Repeat PTCA should be considered carefully for patients falling within a high-risk profile for recurrent events after the procedure.

Determination of the restenosis rate after multilesion percutaneous transluminal coronary angioplasty is an important consideration in denning expanded indica tions for the procedure. Of 209 patients who underwent successful multilesion coronary angioplasty, 55 symptomatic and 74 asymptomatic patients were restudied an average of 7 ± 4 months after dilation. The restenosis rate was 82% (45 of 55) in the symptomatic patients and 30% (22 of 74) in the asymptomatic patients (p < 0.001). Only 4% of the asymptomatic patients had restenosis at more than one dilation site. When only patients who developed a restenosis were considered, the restenosis occurred at more than one dilation site in 47% (21 of 45) of the symptomatic group versus 14% (3 of 22) of the asymptomatic group (p < 0.05). When all recurrent stenoses were examined, the severity of the luminal narrowing was 270% in 64% (45 of 70) of the stenotic lesions in the symptomatic patients versus 31% (8 of 26) of the stenotic lesions in the asymptomatic patients (p < 0.05).Proximal left anterior descending coronary artery disease, increased length of the stenotic narrowing, male gender and diabetes were associated with an increased incidence of restenosis by multivariate analysis. Patient-related variables were not predictive of multilesion restenosis.In conclusion, the majority of patients are clinically improved after multilesion coronary angioplasty. Recurrent symptoms after multilesion coronary angioplasty are frequently associated with multilesion restenosis and a more severe degree of restenotic narrowing. Restenosis at more than one dilation site is uncommon in the asymptomatic patient. The data are useful in formulating guidelines for repeat coronary angiography after multilesion coronary angioplasty.

Inadvertent anastomosis of an aortocoronary vein bypass graft to a cardiac vein is a rare complication of coronary artery bypass grafting (CABG). 1–5 In almost all reported cases, an aortocoronary vein graft was anastomosed to the anterior interventricular vein with formation of aortocoronary vein fistula with different management strategies, including observation without intervention, 2 reoperation with ligation of the fistula and revascularization, 1,3 and transcatheter embolization of the fistula with or without percutaneous transluminal coronary angioplasty [PTCA) of the native vessel. 4,5 To our knowledge, there is no previous report of unintentionally produced internal mammary artery (IMA)-coronary vein fistula with angiographically documented spontaneous closure. We describe 2 cases of iatrogenic left IMA-anterior interventricular vein fistula undergoing spontaneous occlusion 1 and 10 years after surgery, respectively.

Nitroglycerin (NTG) and nifedipine (NIF) have the potential to augment coronary blood flow in addition to reducing peripheral determinants of myocardial oxygen demand as a synergistic protective mechanism during ischemia. To examine these effects, systemic and coronary hemodynamic responses were measured continuously before and during brief periods of myocardial ischemia induced by left anterior descending coronary balloon occlusion in 26 patients undergoing angioplasty (PTCA). Data were compared for two matched occlusion periods, one control and one "drug" occlusion. In 17 patients (NTG group), 200 micrograms of intracoronary NTG was given immediately before coronary occlusion. In nine patients (NIF group), 10 mg of sublingual NIF was given 15 minutes before the "drug" occlusion. NTG significantly but transiently reduced mean arterial pressure (91 +/- 11 to 82 +/- 15 mm Hg, p less than 0.05) and augmented basal coronary blood flow (95 +/- 38 to 127 +/- 54 ml/min, p less than 0.05) but did not alter great vein blood flow (59 +/- 29 vs 61 +/- 29 ml/min) or coronary occlusion pressure (25 +/- 7 to 24 +/- 7 mm Hg) during ischemia. NIF significantly reduced systolic, diastolic, and mean arterial pressure (119 +/- 21 to 95 +/- 8 mm Hg, p less than 0.001) and heart rate-pressure product from control. NIF maintained basal great vein blood flow (125 +/- 41 to 106 +/- 57 ml/min) during reduced myocardial oxygen demand, but did not affect great vein blood flow (73 +/- 29 to 79 +/- 37 ml/min) or coronary occlusion pressures during ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

An 81-year-old man with severe calcific aortic stenosis and coronary artery disease who refused surgical therapy was treated with sequential percutaneous balloon aortic valvuloplasty (PBAV) and percutaneous transluminal angioplasty. Before percutaneous balloon valvuloplasty, the mean aortic gradient was 76 mmHg, and the aortic valve area was .45 cm2. The aortic valve was dilated using 15-mm and 18-mm balloons. The mean gradient decreased to 40 mmHG, and the aortic valve area increased to .62 cm2. Percutaneous transluminal coronary angioplasty (PTCA) was performed 2 weeks later, and an 85% proximal left circumflex stenosis was successfully dilated to 20%. No complications were noted during either procedure. At 6-month follow-up, the patient had returned to normal activities and was asymptomatic. Thus, combined therapy with PBAV and PTCA is technically feasible in selected elderly patients with calcific aortic stenosis and anatomically suitable coronary artery disease. This nonsurgical therapeutic approach may be useful in the treatment of selected patients who refuse or who are deferred from cardiac surgery.

The acute hemodynamic effects of intravenous diltiazem were studied in 8 patients with coronary artery disease, left ventricular (LV) failure (New York Heart Association functional class III), a rest ejection fraction (EF) less than 40% or a cardiac index less than 2.4 liters/min/m2. Hemodynamic measurements and LV angiograms were performed at rest before and after the administration of diltiazem, 0.5 mg/kg, administered at a speed of 5 mg/min. Diltiazem treatment induced a decrease in heart rate from 68 +/- 12 to 55 +/- 9 beats/min (p less than 0.001). Mean aortic pressure decreased from 94 +/- 14 to 81 +/- 15 mmHg (p less than 0.05). Thus, the pressure-rate product significantly decreased under the influence of the drug, from 8,791 +/- 2,465 to 6,342 +/- 1,808 beats mm Hg/min, (p less than 0.001). Diltiazem induced no significant change of LV end-diastolic pressure, pulmonary wedge pressure, cardiac index and LV stroke work index. Systemic vascular resistance decreased (p less than 0.01), whereas pulmonary vascular resistance showed no change. End-systolic volume diminished (p less than 0.02), which accounts for the increase of stroke volume and ejection fraction (p less than 0.001). Disorders of regional contractility were not aggravated by diltiazem, and even improved in individual cases. Thus, intravenous diltiazem may be used safely in patients with heart failure. However, in view of the marked bradycardic effects seen in some cases, heart rate should be carefully monitored.